Traditionally, gastrointestinal endoscopy is mostly a diagnostic procedure where a flexible scope is passed into the stomach or the intestine. However, there is growing interest in the execution of surgical procedures via flexible endoscopes inserted through natural orifices as an alternative to the use of percutaneous laparoscopic instruments. This paradigm shift is being called natural orifice transluminal endoscopic surgery (NOTES). In NOTES procedures, the endoscope is passed through the esophagus and an incision made in the stomach to obtain access to the abdominal cavity. Transgastric access to the abdominal cavity opens a new window for treatment and may be especially beneficial for patients at increased operative risk.
In a handful of academic centers, skilled interventional gastroenterologists and laparoscopic surgeons are collaborating to develop the field of NOTES. Although only a few preliminary experiments using animal models have been published, these studies demonstrate the feasibility and safety of transluminal approach to the peritoneal cavity with long-term survival. The first report published by Kalloo et al. demonstrated the feasibility and safety of the per oral transgastric endoscopic approach. Other transgastric peritoneal procedures in porcine models have been reported including tubal ligation, cholecystectomy, gastrojejunostomy, splenectomy, and oophorectomy with tubectomy. An appendectomy has been performed in a human patient.
NOTES has been the subject of several recent editorials including one calling flexible endoscopic surgery the ‘coming revolution’ in gastrointestinal procedures. The authors contend that the laparoscopic revolution is over and that the next great change in surgery lies in new technology that will allow progressively more aggressive interventions via a natural body orifice. They cite the need for new, flexible instrumentation that will enable surgeons to perform many surgical tasks efficiently. However, rapid progress in this field has been hindered by the lack of adequate instruments that are specifically geared towards performing endoscopic surgery. Most available instruments are mere extended versions of conventional open instruments; open/close handle movements are translated through a slender extension tube to a simple, single degree of freedom effector at the instrument tip. The surgeon's ability to complete more complex procedures is limited by the requisite straight-line access, limited movements of the instrument tip, and the need to exchange instruments to perform different tasks.